Unapproved for Sleeve - Ready to CRY

[jsm 1]

OK.....I work for CareFirst BlueCross BlueShield. I was told by our member services that the Sleeve was covered. I also looked at a copy of our Medical Policy, which states:

Sleeve gastrectomy, performed either as a stand-alone restrictive procedure, or as a first stage procedure of a planned biliopancreatic bypass with duodenal switch for patients with a BMI exceeding 50

So, assumed that since I was just having a stand-alone restrictive procedure, there was no BMI associated with that. However, it appears that CF will only cover the sleeve for patients exceeding 50. This makes no sense to me.

I'm ready to throw-up and cry!

I do not want the bypass. If I appeal, my date of 11/10 is out the window. :confused:

[Chancie 65]

JSM....

I'm sorry this happened, it's so frustrating.... I know...... I went thru it for 3 years. Finnaly- I made up my mind and am a self pay. But I can tell you this...... IF my insurance would have approved ANY of the surgeries... i would have done it, regardless.... I am pleased with my sleeve, but I woulda got the bypass. I just HAD to do something....

[jsm 1]

Thanks Chancie.

Although I've only been communicated to verbally, I've already made some internal inquiries on the best way to handle the appeal process (thank goodness I have some great connections).

Anyway, I need to get some of the latest studies that have been done recently in the USA on the Sleeve.

If anyone has any of this info, would you please post the url's? This is coming at the worse time for me, since I have a huge work deliverable due Friday. Any help will be greatly appreciated! I do have some information that I've compiled for my own documentation, but I did not include the links (dumb me).

Thanks everyone for your support and the support you provide to the members of this forum. The information and sharing here is invaluable.

Hugs,

JoAnne

[DownInSocal 12]

JoAnne I am so sorry this is happenign to you. I just wanted to lend my support. I don't know anything about appeals. I know some here do and the other board has a lot of threads about appeals.

[akindofmagick2 0]

Hi, JoAnne -

United Healthcare now covers the sleeve as "proven" - effective 1 October 2009. Other insurance agencies will likely follow suit shortly. I don't know of any recent studies that will help you - although there are many in process right now. Because of its "investigational" status, the SG procedure is still not so common in the USA right now - so not that many doctors have published their findings, let alone long term findings. The doctors doing the majority of the procedures (Mexico and elsewhere) aren't publishing much, either.... The ASMBS is expected to come out with a statement regarding SG in the near future - but not for several months.

Six months from now things will be very different, I believe.

Do take a look at the insurance forum on obesityhealth.com - there are lots of people fighting their insurance companies there, and some good info.

Bottom line, tho - with your BMI, you will need proof of comorbidities, and very likely also will need six months of supervised weight loss attempts (doctors office or Weight Watchers, etc.).

Which is why I'm going self-pay. BTDT - don't want to wait any longer. (and my company has a WLS exclusion, dammit!)

Sorry not to have better news!

Sheri

[jsm 1]

Thanks all for your support.

I have fulfilled all the requirements PLUS, specified by my insurance company. Additionally, The UM Center for Weight Management & Wellness has additional requirements before they submit to insurance. I made sure my clinicals had every I dotted and T crossed.

What I'm frustrated about is that my member services told me months ago that the sleeve was approved, but never specified the BMI requirement of > 50. I also got a copy of our Medical Policy, and it reads like it's approved as a standalone OR as a first stage with DS later for BMI >50. I sat down with one of our Medical Nurses this afternoon, to get her take on the policy. While she agreed with me, if you go further down in the fine print, you fine the AND between the two procedures.

I will be approved for RNY, but NO WAY! (I'm saying this now!). I did not spend months of research on procedures that I'm not comfortable with.

I'm not giving up hope yet. I will pull together whatever studies are out there and submit an appeal. I know who to go to, and will speak with them in the am.

If it is not approved, then I will just need to save my $$$ to go to MX. I know Dr. Aceves is the best, but he is running no specials and the price not including air is $9500. I see there are several other "all inclusive" with Dr. Fransico Gonzalez, DR. Lisa Marie Gonzalez (LIMARP), Emmanuel Medical, The Bariatric Group.

Does anyone have feedback on these practices/surgery centers, OR any other personal recommendations of MX surgeons ?

Your Help is greatly appreciated! I knew it was too easy up to this point (everything fell into place like magic until today). However, this too shall pass!

Hugs to all,

JoAnne

[Tiffykins 672]

I am sorry you've hit this speed bump in your journey. I thought this thread may lend you some useful information. Another member on here cites a lot of useful references and research.

http://verticalsleevetalk.com/insurance-financing/1496-my-appeal-draft-w-references.html

[jsm 1]

Thanks so much Tiffykins! I am beginning to pull research now for my appeal. I will put positive energy in this process and bless the outcome no matter what it is. The hurdles we face with insurance can only pave the way for others.

Hugs,

JoAnne

[Malaika 50]

JoAnn - sorry for the bad news - I HATE the way they write policy information - as it can be interpreted different ways by different people.

What is your current BMI?

I agree with you - I would NEVER get a procedure with which I wasn't comfortable even if the insurance would cover it.

I wish you luck on your appeal.

I had my surgery with Dr. Aceves and he is totally wonderful. I wouldn't sacrifice my health to save a few hundred (or even thousand) dollars.

I don't know about the other doctors; however, I am sure others on here do or at the other site.

If you decide to have it done in Mexico all I can recommend to you is RESEARCH, RESEARCH, RESEARCH and don't let the discounted price be your deciding factor.

[TennJenn 9]

I can't offer any advice regarding insurance. I didn't qualify through my insurance company (BMI 34.5) so I went immediately to self pay in Mexico. I do encourage you to research Mexican surgeons. There is a thread stickied here somewhere from a former member that is a huge help in how to research Mexican surgeons. I suggest reading it in its entirety.

Good luck.

[carolyn24seven 11]

Jo Ann I am so sorry you have this huge let down just when you thought things were going your way. You sound like a fighter and I wish you the best of luck.

I am being sleeved tomorrow. Dr. Almanza at the Emanuel Clinic in TJ. I did months of research before I chose this Dr. I could have just as easily gone to Dr. Aceves. It really is a personal choice. I will keep posting on here if you want to follow my story.

I hope for you that you will win your appeal.

[Bob_350lbs 105]

Jo Ann, so many of us went through the exact same thing..Dr. Almanza in MX is supposed to be very affordable, a lot of folks here have posted their glowing experiences under a heading using his name. And, Dr. Aceves has lot of rave reviews too. P.S. Best wishes Carolyn, you'll do great!

If you want to wait for the insurance co to decide it's no longer experimental, then you have more patience than I do. I wish the best for you regarding this. My BMI was 39 and I had no comorbities..so I was screwed..

What do the insurance co want from us? How fat do we have to get? How many other risk factors do we need? Don't they know the leading cause of death in America is due to heart disease and heart disease is directly related to obesity..it really irks me..because that means obesity is the leading cause of death in America.

They don't cover ultra sounds of the carotid arteries either, unless you are having symptoms of mini strokes, etc..but having this ultra sound is a number one way non-invasive way to know if you are also having narrowing of the arteries around the heart, i.e. potential heart attacks.

And, the call themselves HMO. What a joke. This simple test could prevent future heart attacks. I am thinking of paying out of pocket the $200 for this test. Probably, that's what they are hoping for.

I could have heart disease, both my parents did, and I have that dangerous abdominal fat. So my EKG was normal, my bp is normal, doesn't mean my arteries haven't started clogging up. Most likely the have. That is a serious comorbidity of everyone who is obese..how can it not be? Even autopsies on children arefinding their arteries already clogging.

Hey, maybe you should have this test done..there's your comorbidity. It would be worth the money.

Edited October 15, 2009 by Steph_123

[jsm 1]

Carolyn, will keep you in my thoughts and prays for a safe surgery and speedy recovery. Can't wait to read your updates!

Steph, I totally agree with you about the health care hoops. I work for CareFirst BlueCross BlueShield. I am very familiar with the pre-cert process, and was so careful to make sure all my I's were dotted and T's crossed. Well, in my appeal, I have pointed out that the Position Study referenced in our Medical Policy for Obesity, is no longer available on the WWW. I'm hoping that in itself will be a factor for approval. I have provided many references of recent VSG studies. Additionally UHC, our competitor has reversed their Medical Policy this month stating that VSG is proven in adults for the treatment of clinically severe obesity (35-39.9 kg/m2 - Obesity Class II (Severely Obese)). My CareFirst Medical Policy will only approve if BMI > 50.

I truly believe that the tide is slowly turning with physicians, specialists and Health Care Insurers, seeing the benefits of WLS. Recent studies for VSG can only help to get this procedure approved with the same criteria as RNY and Gastric Banding.

Should my appeal is denied, I will have to regroup and reconsider RNY or self pay in Mexico. However, I'm still not giving up hope for approval!

Hugs to All,

JoAnne

[Sandy Johnson 15]

JSM, Your appeal date may not be out the window! Try to appeal the decision NOW! Write a letter and send it overnight mail (with a return receipt) stating your reasons. Quote their own statement of "performed either as a stand-alone restrictive procedure, OR as a first stage procedure of a planned biliopancreatic bypass with duodenal switch for patients with a BMI exceeding 50" It is possible to get a decision within a few days. Mention in your letter that you have a surgery date scheduled. It's worth a try!

[mountain_lover 3]

Carolyn, will keep you in my thoughts and prays for a safe surgery and speedy recovery. Can't wait to read your updates!

Steph, I totally agree with you about the health care hoops. I work for CareFirst BlueCross BlueShield. I am very familiar with the pre-cert process, and was so careful to make sure all my I's were dotted and T's crossed. Well, in my appeal, I have pointed out that the Position Study referenced in our Medical Policy for Obesity, is no longer available on the WWW. I'm hoping that in itself will be a factor for approval. I have provided many references of recent VSG studies. Additionally UHC, our competitor has reversed their Medical Policy this month stating that VSG is proven in adults for the treatment of clinically severe obesity (35-39.9 kg/m2 - Obesity Class II (Severely Obese)). My CareFirst Medical Policy will only approve if BMI > 50.

I truly believe that the tide is slowly turning with physicians, specialists and Health Care Insurers, seeing the benefits of WLS. Recent studies for VSG can only help to get this procedure approved with the same criteria as RNY and Gastric Banding.

Should my appeal is denied, I will have to regroup and reconsider RNY or self pay in Mexico. However, I'm still not giving up hope for approval!

Hugs to All,

JoAnne

I have a question: Does BlueCross BlueShield approve The Duodenal Switch and if so what are the requirements?

Why I am asking is to let you know what happened to me. I changed my mind about having a band and decided to have a Dueodenal Switch or a VSG surgery. When I had my first appointment with Dr. Husted here in Somerset Ky., he told me that he would prefer that I had a VSG instead of the Dueodenal Switch. I assume that is because of my BMI being at 43 at the time. I found out that the Dueodenal Switch was covered by Medicaid, but at the time the VSG procedure was not. He told me not to worry about it, because he was going to submit more information to Medicaid to try to get it to be a covered procedure. Now several months later I have been told that Medicaid is covering it for some patients. From what I understand the VSG is the first part of the Dueodenal Switch. The Duedenal Switch is a more evasive surgery with much more involvement than the VSG. The VSG is only restrictive and the Dueodenal Switch is restrictive and Malabsorptive. The Vsg has less comlications and surgery time is less and heal time is faster.

The patients with very high BMI's and other health issues who needed surgery but were not heallthy enough to have the Dueodenal Switch, would have the first restrictive part of the Dueodenal Switch where part of the stomach was removed, so they could lose enough weight and be at a healthier place in time to have the other part of the Dueodenal surgery where everything is rearranged for it to become Malabsorptive. What the Doctors found out over time was this; the patients were losing weight and most of them were becoming healthier in the process and they were getting closer and closer to their desired weight. Many doctors and patients discovered that the other surgery was not required. So the VSG surgery is becoming a more popular and excepted procedure among the healthcare professionals and insurance companys. It is safer and less expensive than some of the other surgeries. As they say; IF IT WORKS, DON'T FIX IT. The insurance companies will eventually all agree that it will be better to do the VSG surgery before doing the more evasive riskier procedures. Then if that doesn't work for some, then they might still have to go in for the other part of surgery, to complete it for more weight loss for those who have had very high BMI's or other health issues. (Why pay for more than what is needed and Why put the patients through more than they need to go through, just so that the insurance companys don't have to change their current policies or have to deal with any hassles?) It all makes sense to me now and that is why I am hanging in there and hoping that Dr. Husted and his team can do what is best for me and get the VSG surgery approved for me, that way I will not have to go through the more evasive surgery unless I absolutely have to. I am really happy with their services and their concern for my well being. I hope the best for you and the others that are having difficulty getting the VSG surgery approved by your insurance. BEST WISHES!!

Edited October 17, 2009 by mountain_lover